We in the elder care community have much work to do for culture change regarding elders in our country. As a Geriatrician providing house calls in the San Francisco Bay Area, I see many sad cases of elder abuse and many that are missed due to allowing the elder's "right to folly". In the New York Times column called ‘The Ethicist’ a reader wrote in on 6/26/16 with the question; Can You Keep a Woman From Courting Your Elderly Dad?

The question focused on whether it was ethical for the adult children to intervene about a relationship their elderly, financially secure father is engaging in with an employee of the assisted living community in which he lives. The story detailed that not only are they ‘friends’, but that she asked him to give her narcotics for which he was prescribed for cancer, (which he did), that she is now driving him to the doctor and that she has asked him to take their relationship ‘to the next level’. The children are afraid that she is planning to take over his care and finances and are suspicious of her motives.

The response from the New York Times ethicist was that basically it was the dad’s decision to be in the relationship. From the information provided, the ethicist concluded that the dad seems to have the capacity to still make his own decisions. The ethicist suggested that the adult children were more worried about their inheritance and ‘being taken care of’ after the dad’s death than anything else.

But the question remains unanswered to me. Can the dad really still make those decisions? Has he been properly evaluated? The adult children noted that he would get confused and was becoming more debilitated and frail. What was missing from the ethicists answer was the clear steps to assess and protect a vulnerable elder.

Engaging a good elder law attorney is important to be sure that the dad is legally protected. Even if this man has capacity, he is at high risk for undue influence. Undue influence is the substitution of another person's will for the victim's will (i.e. the decisions benefit the other, not the elder). The first step is to have a geriatrician's assessment. Are the medications clouding his thinking? A screen such as the MoCA (Montreal Cognitive Assessment) is better at detecting decline in abstract thinking than the MMSE (mini-mental status exam). These are just screens, and in a case like this, I would advise to have gero-neuropsychological testing to determine the capacity for the elder. Financial capacity requires more abstract thinking, judgment and risk assessment. Those two steps are necessary to protect the money and health care of an elder who cannot assess the situation as they might have twenty years earlier.

Of course, if the money is secure and the woman is just interested in his company he should be free to enjoy her company. But it is particularly important to be aware and cautious given some of the details in this case; that the woman solicited him for narcotics, (which is a felony); kept their relationship ‘secret’, (which is prohibited for community employees and residents); and seems to be in a position to financially abuse this gentleman. It's not that an older man should not have an "Anna Nicole Smith" if he likes; but in that case, others need to make sure he can understand the risks and benefits of the relationship. That is a difficult task at any age.